New Guidelines Reveal Answer for Lower Back Pain

Approximate read time: 3 minutes

NY Times:

Saying active with lower back pain is not bad advice.

But what does “staying active” mean?

Dr. Weinstein suggests, “I know your back hurts, but go run, be active instead of taking a pill.”

It’s not that I think you should take a pill. I question the logic of running or being that active when your lower back hurts.

I did that once. I fell trying to dunk a basketball. I did the “stay active” thing and even did the running part but the problem was I had fractured part of a lumbar vertebrae.

That was spectacularly dumb.

Makes me wonder if Dr. Weinstein has ever had to follow his own advice.

And I wonder if we, in the medical world, give that advice to people with other types of orthopedic injuries, say, an ankle sprain.

I don’t know anyone who would suggest running on a sprained ankle. But if you sprain your back, somehow that’s okay.

Part of the problem is that people want to be out of pain fast. Everything is fast now. Internet is fast. Order on Amazon, get it in a day. Need at ride? Uber in 10 minutes. Stream TV and movies whenever you want to. No need to go to a store, rent a movie, get hit with late fees.

We expect speed.

It’s complicated. Articles like this one in The NY Times can’t capture the personal impact back pain has on people. People have to go to work, tend to family needs and responsibilities.

The pain is in the way.

The body dosen’t care about that. It heals according to its’ own rules.

Then the healthcare system doesn’t pay doctors to explain anything. They get paid by procedures billed.

There’s no money in teaching you why you hurt, what it means, what options you have, how to manage it, what “stay active”means.

So if you tell someone who hurts, who has taken the time to come in to see you, waited for over an hour sitting on a hard, uncomfortable waiting room chair, “Don’t worry about it, you’ll be fine, stay active”, and you don’t take the time to explain it, you end up with an unhappy, confused patient.

Since there’s no time to explain anything, doctor’s have to DO something.

So you get a med. NSAID or pain med or muscle relaxer. Something. Maybe a physical therapy referral.

And off the patient goes on a hike through the Amazon jungle of back pain. Some people make it through okay. 1)Coste J, Delecoeuillerie G, et al. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ 1994;308(6928):577–580.

The recurrence rate though is high. In the 80% range.

The secret to solving lower back pain isn’t as simple as telling people to stay active.

A friend has a neighbor, Bill (not his real name), who is 90 years of age. You would never guess that if you met him. His movement is crisp, quick. He has a bounce in his step. He stands tall.  He works in his yard almost every day. An active guy.

He went to NYC with his daughter. While there, they spent hours and hours and days and days walking the concrete streets to take in the sites.

Bill gets home and can barely stand up. Shuffling kind of walk. Stooped, crooked. Miserable.

After a few weeks, and now using a walker to get around, he goes to his family doctor who says it’s a muscle strain, to “stay active” and sends him to a physical therapist.

The therapist suggests that Bill’s problem is lack of core strength and he’s not flexible enough (did I mention he was 90?), and started him on stretching exercises and core exercises.

Two weeks later, Bill is worse.

He’s bent over like he’s walking though the front door of Bilbo Baggins house.

This is when my friend talked to me. He wanted to know if there was anything else that could be done because, “I’m watching a guy go down hill in a hurry.”

After hearing the story, I said, “He needs at least an x-ray and a consult with a surgeon. Good chance, he has a pre-existing, dormant spinal stenosis. Not symptomatic. But all that walking on concrete probably trashed his bony structure. He’s headed for surgery.”

An MRI revealed a collapse of the bony structure of one of Bill’s lumbar vertebrae. He had surgery.

A week later he was back in his yard. That was not my advice by the way. I thought a more gradual return to activity made sense.

See, if you look through the lens of a symptom rather than the underlying pathology, you end up with generic back pain in a 90 year old guy and assume it’ll get better…back pain gets better no matter what you do is the thinking…until it doesn’t.

Sometimes the pathology, what’s injured, damaged, diseased, overrides everything else like inadequate core strength, flexibility, or funky mechanics. There was nothing other than surgery that would have helped Bill.

I ran into Bill in October and he looked great. The bounce in his step was back. He stood tall. Moved with ease.

Bill made it through the jungle.

Telling Bill to stay active without a clear understanding of his problem only made him worse and delayed what he needed.

Staying active with lower back pain is a good idea but it’s not a solution. It might be part of the solution as long as you’re clear on what being “active” means.

Examples of exercises often used:

References   [ + ]

1. Coste J, Delecoeuillerie G, et al. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ 1994;308(6928):577–580.